Request for In-Depth Health Analysis Report

Print this page, fill in the required information, sign and date it, keep a copy for your records and enclose payment. Mail or fax to the address at the bottom of the page. Our underwriter will contact you with the results of the evaluation.

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

I authorize Asset Protection Network, Inc. (referred to as APN, Inc.), its affiliates, its reinsurers, insurance support organizations and their authorized representatives to obtain medical and other information in order to evaluate my application for insurance. I authorize my physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance company, the Medical Information Bureau, Inc., consumer reporting agency, or other medical organization, institution or person having information available as to other insurance coverage, medical care, treatment, supplies or advice with respect to me to furnish such information to APN, Inc., its reinsurers or their authorized representatives.
This authorization will be valid from the date signed, for a period of 2 1/2 years (26 months in Minnesota). I agree that a copy of this authorization is as valid as the original.
I or my authorized representative have/has read this authorization and understand that I have the right to receive a copy. I acknowledge receipt of the following notices regarding:

• Notification Regarding Use and Release of Medical Information to the Medical Information Bureau, Inc., and other Life Insurance Companies (click to view)
• Guide to Health Insurance For People with Medicare (download)
• NAIC Shopper's Guide to Long -Term Care Insurance (download)
• The Fair Credit Reporting Act (click to view)
• Disclosure Statement (see above)

DECLARATION / CERTIFICATION

I authorize APN, Inc. to obtain my medical records for use in evaluating my application for insurance.

Full Name _________________________________________________
Address __________________________________________________
City ___________________________State_______Zip_____________
Social Security # _______________________Date of Birth __________
Phone _____________________

Signature of proposed insured __________________________________
Witness __________________________________________________
Date signed __________________________(month, day, year)

I was referred by __________________________(representative's name)

My primary physician's name __________________________________
Address __________________________________________________
City __________________________State________Zip_____________
Phone _____________________

Need all medical records for the last 5 years, to include all office notes, lab results and pathology tests. SUMMARIES ARE NOT ACCEPTABLE FOR LTC UNDERWRITING.

In-Depth Health Analysis Cost $40.00 per applicant

Make checks payable to 'Asset Protection Network, Inc.'
or pay online using our secure shopping cart.

Requested Plan Design

Any health care information developed is necessary to classify insurance risks, conduct normal administrative procedures and process claims, and will be used for those purposes only. No other use of this information will be made without first obtaining your written consent.
The information will be treated as confidential, except that APN, Inc. or its reinsurer(s) may make a brief report to The Medical Information Bureau, Inc., a non-profit membership corporation of life insurance companies which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you have applied for life or health insurance coverage or to which a claim is submitted, the Bureau will supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your files. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112, Telephone (617) 426-3660.
APN, Inc. or its reinsurer(s) may release information given in your application file, including health care information, to other life insurance companies to which you may apply for life or health insurance or to which a claim is submitted.

The Fair Credit Reporting Act requires that no investigative report be made on any consumer unless:
1. That person to be reported on has been give written notice that such a report may be or has been requested, and
2. That person is informed that he/she has the right to ask for disclosure of the type of information being sought.
As part of our underwriting procedure, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigation is made, you can be assured it will be handled in the strictest confidence.
If you wish information on the nature and scope of the Consumer Report which may be requested, just contact APN, Inc.

Mail or Fax to:

Asset Protection Network, Inc.
900 Hendersonville Road, Suite 310
Asheville, NC 28803-9822

Phone  (828) 274-7655
Toll Free 1-800-373-6639
Fax (828) 274-0408